Alarm fatigue symbolizes the limits of technology

A few months ago while I was working in the interventional gastrointestinal unit I noticed something because it was driving me nuts. One of the monitors in the holding area that slaved to one of the procedure rooms was beeping. Just a low, constant blip blip blip blip. The screen read, “no data.”

So I asked one of the nurses “can we turn that monitor off? No one is using procedure room 3.”

She says to me, “Nobody knows how to uncouple the slave.”

I said, “doesn’t that constant beeping bug you?”

“Oh we don’t even hear it anymore.”

Boston Medical Center is taking steps to decrease what is called alarm fatigue, in which people who work in the health care environment every day simply stop hearing all the beeping from all the various machines and monitors that are attached to patients. They don’t become deaf. They are victims of two psychological processes: habituation and learned helplessness.

Habituation of course is when you get so used to something it seems normal, or you get so used to something you don’t notice it anymore. The reason health care professionals stop noticing alarms is because they have learned that they are usually meaningless. If a patient is attached to a heart monitor the machine will alarm whenever it sees something that isn’t normal sinus rhythm. If the patient moves in the bed it goes off. If one of the leads falls off it goes off. If the patient coughs or rubs their nose it goes off. If the patient is not even in the room it will continually go off exclaiming loudly that there is “no data.”

If the patient has a condition in which their heart rate is unusually high the monitor will go off every three minutes, exclaiming “tachycardia.” If the patient is an athlete and has an unusually low heart rate the monitor will go off every three minutes exclaiming “bradycardia.”

“Patient not breathing!” says the monitor.

Well that’s because there’s no patient hooked up to the breathing machine.

“Asystole!” the machine says when one of the leads on the EKG is pulled off by accident.

“ST elevation!” it will yell in the face of a normal EKG on an 18-year-old.

“Ventricular fibrillation!” it will scream if the surgeon is using cautery too close to your leads. If you work in an environment in which large numbers of alarms are going off, none of which are real, the tendency is to stop responding.

The other process is learned helplessness, and it was made famous by two guys named Seligman and Maier, who gave electric shocks to three groups of unfortunate dogs. One group got shocked no matter what they did, so eventually they quit trying to get away. Same with health care folks. Those alarms are going to go off all the time no matter what you do, so you just accept the background noise and go on with your day. The problem with all this of course is that every once in a while the monitor is right.

When I was a nurse in a telemetry unit back in the 90s we still had nurse’s assistants who worked as monitor watchers. It was the most awesome thing ever. This person would sit at a bank of monitors all day and actually look at and evaluate every alarm. She silenced the ones that were false, saved strips of things that looked real but were brief to show to the nurse, and yelled loudly when something was really wrong.

This person did a number of things for the nurses:

She relieved them of the constant underlying anxiety of beeping monitors you can’t see.

She kept the noise down.

She watched. She was there. Monitored patients were actually truly monitored. By a person.

These monitor watchers no longer exist, of course. Too expensive. So now we are left with electronic monitoring by machines that are only as smart as the data they are presented with, out of context and without clinical correlation.

I don’t know exactly what Boston Medical Center is doing to reduce alarm fatigue, but the only way to really do it is use people. That’s right, hire people to help. To watch. To evaluate. Or hire more nurses so the nurses can watch more effectively.

In the OR the alarms are not a problem because there’s an anesthesia provider who sole responsibility is to monitor one patient. So it’s easy to respond to every alarm appropriately. Anesthesiologists don’t get that same alarm fatigue because they have the ability to immediately respond and decide if an alarm is real or not based on the context of the situation. A nurse on the floor can’t do that with 6 patients whom she also has to feed, clothe, and medicate. To take care of people you really need other people. Eventually you run into the limits of technology.

Alarm fatigue symbolizes the limits of technology 6 comments

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Rob Burnside

This is a serious problem for all the reasons listed. The fire service has its own version–“touchy” building fire alarm systems that false too frequently and cause residents to disregard the alert. These can usually be adjusted, and it makes me wonder why those used in health care can’t be tweeked as well. Anything that adds anxiety and fatigue to a job already charged with plenty of both needs to be reconsidered. Clearly, however, the very best solution is reinstatement of the nurse monitor, as Dr. Leng suggests.

LALynn

The linked editorial explains why the growing alarm fatigue problem has not (and cannot) be solved within the 20th century threshold paradigm. The editorial tell an startling, incredible but sad story of a monitoring threshold “science” fossilized on an utterly simplistic 20th century century theory.

This editorial and the cited reference “The patterns of unexpected in-hospital death” are must reads for anyone truely trying to understand and/or solve the ubiquitous and growing alarm fatigue problem as well as the problem of delay in acute diagnosis (such as sepsis).

Happened in my ED, and led to a patient demise…. loads of meetings and action plans later? Staff are STILL not setting alarm limits to the patients condition, and after a brief period of heightened awareness, the “alarm fatigue” and tuning them out is creeping back…..

lotzakids

Because my son is trach/vented, he gets his own nurse when on the floor. I always stay, but I’m not usually needed. His last stay, I waited and waited for a nurse to check on his low O2 alarm (the reason he was in the hospital in the first place). She never even opened the door, just kept silencing the alarm. I finally suctioned him out, turned up the O2, and opened the door and firmly told her that I expected her to actually CHECK on him, not simply press the button at the desk. She tried to tell me she had done so 5 minutes before to which I replied that I’d been awake for 45 minutes and had not noticed her. And THAT is why I never leave my son alone in the hospital. Some may call it alarm fatigue. I call it downright dangerous.

Sarah Williams

I appreciate and concur there is serious negative impact to
our healthcare providers and increased risk to patient safety due to the shear number of alarm sounds going off in our hospitals today. However, committing more human resources for the purposes of monitoring alarms is not the most effective way to achieve this goal today. There are many medical devices as well as other systems within a healthcare setting that are contributing to alarm fatigue that cannot be monitored at a central location. For example,
ventilators, IV pumps, free standing pulse oximeters, smart beds, and nurse call systems just to name a few.

The technology exist today that can address the majority of
the issues. There are multiple whitepapers indicating a need to change our practice to only use the audible feature for life critical, actionable events. I would hypothesize the if we were to use a 3rd party software that can aggregate data elements from multiple sources and present contextual alarms, alerts and notifications to the care providers, noise would significantly be reduced, thereby reducing alarm fatigue and increasing patient safety.